Undergoing Shoulder Arthroscopy Research Articles

Systemic and cerebral hemodynamic changes in patients undergoing shoulder arthroscopy in the beach chair position

Поєднання таких факторів як загальна анестезія та зміна положення тіла після індукції мають вплив на системну та церебральну гемодинаміку. Мета. Bиявити вплив зміни положення тіла та загальної анестезії на пікову систолічну швидкість внутрішньої сонної артерії (ПСШВСА) у пацієнтів під час проведення артроскопії. Методи. 85 пацієнтів із фізичним статусом за ASA I–II, середнього віку (33,0 ± 11,3) років, проведено артроскопію плечового суглоба під загальним наркозом. Основними вимірюваннями були систолічний артеріальний тиск (САТ), діастолічний артеріальний тиск (ДАТ), середній артеріальний тиск та ПСШВСА. Основні вимірювання: в положенні лежачи на столі перед індукцією, через 3 хв після введення в наркоз в положенні лежачи та в положенні пляжного крісла (ППК). Індукцію та забезпечення загальною анестезію проводили сибазоном, пропофолом і фентанілом. Дані проаналізовано статистично. Методи описової статистики використовували для розрахунку середнього, стандартного відхилення, мінімального і максимального значень вибірки. Порівняння проводили за допомогою Т-тесту для повторних порівнянь з розрахунком різниці середніх зі стандартним відхиленням (M ± SD), критичного значення критерію (t) та його статистичної значущості (p). Для порівняння динаміки зміни параметрів було проведено загальний лінійний аналіз з визначенням значення критерію Піллаї та його значення. Аналіз проводився в пакеті IBM SPSS Statistics 20.0. Результати. Початкові дані САТ, ДАТ та середнього артеріального тиску достовірно знижувались після індукції та після позиціонування, але індукція не вплинула на показник ПСШВСА. Після позиціювання до ППК було констатовано значне зниження показників ПСШВСА. Висновки. Констатовано достовірне зниження САТ, ДАТ, середнього артеріального тиску після индукції та подальшого позиціювання хворих у ППК. Постіндукційна гіпотензія не впливає на динаміку ПСШВСА, але виявлено достовірне її зниження після позиціювання.

Total Intravenous Anesthesia with Propofol Reduces Discharge Times Compared with Inhaled General Anesthesia in Shoulder Arthroscopy: A Randomized Controlled Trial.

Shoulder arthroscopy is commonly performed at ambulatory surgical centers (ASCs) with use of an interscalene block and inhaled general anesthesia (IGA). However, an alternative option known as total intravenous anesthesia with propofol (TIVA-P) has shown promising results in reducing recovery time for other surgeries. The objective of this study was to assess whether there is a clinically meaningful difference in post-anesthesia care unit phase-I (PACU-I) time following shoulder arthroscopy between patients receiving an interscalene block with IGA and those receiving an interscalene block with TIVA-P. Patients who underwent shoulder arthroscopy performed by a single surgeon at the ASC of our institution between 2020 and 2023 were enrolled. Enrollment was conducted in blocks, with up to 3 planned interim analyses. After 2 blocks, enrollment was halted because the study arms demonstrated a significant difference in the primary outcome measure, PACU-I time. A total of 96 patients were randomized into the TIVA-P and IGA groups; after patient withdrawals, the groups comprised 42 and 40 patients, respectively. Patients underwent shoulder arthroscopy with use of the anesthesia method corresponding to their assigned group. Pain, satisfaction, antiemetic use, perioperative interventions, surgical time, PACU-II time, postoperative care time, and total time until discharge were recorded and were analyzed with use of chi-square and Mann-Whitney U tests with a significance cutoff of 0.0167 to account for the interim analyses. Across groups, 81.7% of patients were non-Hispanic White and 58.5% were male. Significant differences were observed between the TIVA-P and IGA groups with respect to median PACU-I time (0.0 minutes [interquartile range (IQR), 0.0 to 6.0 minutes] versus 25.5 minutes [IQR, 20.5 to 32.5 minutes]; p < 0.001) and median total time until discharge (135.5 minutes [IQR, 118.5 to 156.8 minutes] versus 148.5 minutes [IQR, 133.8 to 168.8 minutes]; p = 0.0104). The TIVA-P group had a 9.1% quicker discharge time, primarily as a result of bypassing PACU-I (66.7% of patients) and spending 25.5 fewer minutes there overall. The TIVA-P group also had a lower rate of antiemetic use than the IGA group (59.5% versus 92.5% of patients; p = 0.0013). No significant differences were detected between the TIVA-P and IGA groups in terms of median pain improvement (1.0 [IQR, 0.0 to 2.0] versus 1.0 [IQR, 0.0 to 2.0]; p = 0.6734), perioperative interventions (78.6% versus 77.5% of patients, p = 1.0000), or median patient satisfaction (4.0 [IQR, 4.0 to 4.0] versus 4.0 [IQR, 3.8 to 4.0]; p = 0.4148). TIVA-P showed potential to improve both PACU-I time and the total time until discharge while reducing antiemetic use without impacting pain or satisfaction. TIVA-P thus warrants consideration by orthopaedic surgeons for use in shoulder arthroscopy performed at ASCs. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

High accuracy of intra-articular needle position during anterior landmark guided glenohumeral injections

ObjectivesImage-guided ultrasound or fluoroscopic glenohumeral injections have high accuracy rates but require training, equipment, cost, and radiation exposure (fluoroscopy). In contrast, landmark-guided glenohumeral injections do not require additional subspecialist referrals or equipment. An optimal technique would be safe and accurate and have few barriers to implementation. The purpose of this study was to define the accuracy of glenohumeral needle placement via an anterior landmark-guided approach as assessed by direct arthroscopic visualization. MethodsA consecutive series of adult patients undergoing shoulder arthroscopy in the beach chair position were included in this study. Demographic and procedural data were collected. The time required to perform the injection, the precise location of the needle tip, and factors that affected the accuracy of the injection were also assessed. ResultsA standardized anterior landmark-guided glenohumeral joint injection was performed in the operating room prior to surgery, and the location of the needle tip was documented by arthroscopic visualization with a low complication profile and few barriers to implementation. A total of 81 patients were enrolled. Successful intra-articular glenohumeral needle placement by sports medicine and shoulder/elbow fellowship-trained orthopedic surgeons was confirmed in 93.8% (76/81) of patients. The average time to complete the procedure was 24.8 ​s. There were no patient-related variables associated with nonintra-articular injections in the cohort. ConclusionsThis study demonstrated that the technique of anterior landmark-guided glenohumeral injection has an accuracy of 93.8% and requires less than 30 ​s to perform. This method is safe, yields similar accuracy to image-guided procedures, has improved cost and time efficiency, and requires less radiation exposure. No patient-related factors were associated with inaccurate needle placement. Anterior landmark-guided glenohumeral injections may be utilized with confidence by providers in the clinical setting. Level of EvidenceLevel 5.IRB: Approved under Stanford IRB-56323.

Analgesic Efficacy of Suprascapular Nerve Block versus Combined Suprascapular and Axillary Nerve Block in Patients Undergoing Shoulder Arthroscopy: A Prospective, Randomized, Comparative Study

Abstract Background: Immediate post-operative pain can be severe and is an important outcome measure for patients in shoulder arthroscopic surgeries. Interscalene block is the most widely used and studied technique for post shoulder arthroscopy pain relief and is associated with certain unpleasant adverse effects. Suprascapular nerve block (SSNB) has been suggested as an alternative and safer block. As the suprascapular nerve contributes to 70% of the sensory nerve supply to the shoulder joint, and the axillary circumflex nerve is the other major nerve contributing to 25%; therefore, a combined block of these two nerves should provide more effective pain relief than SSNB alone. Aim: This study aimed to compare the efficacy of combined SSNB and axillary nerve block (ANB) with SSNB alone for analgesia after shoulder arthroscopy in terms of level of pain scores, total analgesic consumption, and patient satisfaction in 24 h. Methods: Forty-one patients posted for shoulder arthroscopy were randomly allocated into two groups, Group S (n = 20) receiving SSNB and Group C (n = 21) receiving combined SSNB and ANB. Visual Analog Scale (VAS) both at rest and during movement at 1, 3, 6, 12, 24 h, and at the time of first demand, total consumption of analgesics in 24 h and patient satisfaction score at 12 and 24 h were noted. Statistical Analysis: The data was analyzed by Student’s t-test, Mann-Whitney U test, and Fisher’s exact test using Graph Pad PRISM 9, a p&lt;0.05 was considered significant. Results: The VAS scores both at rest and during movement were significantly less in Group C at 1, 6, 12 h, and at the time of the first demand of analgesic (p&lt;0.05). Compared to Group S, Group C had a longer pain-free duration (154.3 ± 11.41 min vs. 36.60 ± 6.553 min; P &lt; 0.001) and lesser cumulative consumption of pethidine (300.0 ± 8.894 mg vs. 336.8 ± 13.27 mg; P = 0.0256). The satisfaction level was better in Group C at 12 h (P = 0.002) but comparable to the Group S at 24 h (P = 0.0673). Conclusion: Combined SSNB and ANB provided better pain relief in first 12 h, better patient satisfaction in the first 12 h and decreased overall consumption of analgesics in the first 24 h compared to SSNB alone.

Anatomic factors associated with degeneration and fraying of the coracoacromial ligament.

The coracoacromial ligament (CAL) is frequently observed to be damaged during arthroscopy and it is unclear how demographic, anatomic, and radiographic factors are related to CAL degeneration in full-thickness rotator cuff tears. A prospective study was conducted of patients at a single institution undergoing shoulder arthroscopy for first-time, full-thickness rotator cuff tears. We evaluated preoperative anteroposterior radiographs to obtain critical shoulder angle, glenoid inclination, acromial index, acromiohumeral distance, lateral acromial angle, and acromial morphology. We documented CAL quality, rotator cuff tear size and pattern during arthroscopy. Multiple logistic regression was used to identify predictive factors for encountering severe CAL fraying during arthroscopy. Shoulders had mild CAL degeneration in 58.1% of cases, whereas severe CAL degeneration was present in 41.9% of shoulders. Patients with severe CAL attrition were significantly older (62.0 years vs. 58.0 years, P=0.042). Shoulders with severe CAL attrition had large rotator cuff tears in 54.1% of cases (P<0.001), and tears involving the infraspinatus (63.2% vs. 29.6%, P=0.003). The severe degeneration group was more likely to have a larger critical shoulder angle measurement on preoperative radiographs than those in the mild attrition group (36.1°±3.6° [range, 30°-45°] vs. 34.1°±3.8° [range, 26°-45°], P=0.037). While the clinical impact of CAL degeneration remains uncertain, increased severity of CAL degeneration is associated with older age, larger rotator cuff tear size, presence of infraspinatus tearing, and increased preoperative critical shoulder angle. Level of evidence: III.

Effect of pre-infusion of hypertonic saline on postoperative delirium in geriatric patients undergoing shoulder arthroscopy: a randomized controlled trial

BackgroundNeuroinflammation may be a potential mechanism of postoperative delirium (POD) in geriatric patients, and hypertonic saline (HS) has immunomodulatory properties. The purpose of this study was to investigate whether HS could reduce the incidence of POD in elderly patients and its effect on neutrophil activation and inflammatory cytokine expression.MethodsWe studied the effect of pre-infusion of 4 mL/kg 3% hypertonic saline vs. 4 mL/kg 0.9% normal saline on POD in patients undergoing shoulder arthroscopy in a prospective, randomized, double-blind, controlled trial. Neutrophil surface molecules (CD11b, CD66b and CD64) were analyzed by flow cytometry. Circulating concentrations of inflammatory factors IL-1β, IL-6, TNF-α and neurological damage factor S100β were assessed by enzyme immunoassay. The Confusion Assessment Method-Chinese Revision (CAM-CR) was applied for the assessment of POD 1–3 days after surgery.ResultsThe incidence of POD in group H was significantly lower than that in group N (7.14% vs 26.83%, P = 0.036). The expression levels of inflammatory cytokines ( IL-6 and TNF-α) and neutrophil surface markers (CD11b and CD66b) were significantly lower in group H than in group N at 24 h after surgery (P = 0.018, P < 0.001, P < 0.001, P = 0.024). There were no significant differences in postoperative pain, nausea and vomiting, infection, phlebitis, and patients satisfaction between the two groups.ConclusionPre-infusion of HS can reduce the incidence of POD and the immune-inflammatory response.Trial registrationChinese Clinical Trial Registry (14/4/2022, registration number: ChiCTR2200058681.

Efficacy of biceps-radial-slice magnetic resonance images for the diagnosis of biceps and pulley lesions.

Injuries to the biceps reflection pulley lead to instability of the long head of the biceps tendon. However, conventional magnetic resonance imaging has low diagnostic accuracy for long head of the biceps tendon and pulley lesions. Here, we investigated the usefulness of novel biceps-radial magnetic resonance imaging for evaluating long head of the biceps tendon and pulley lesions. Biceps-radial magnetic resonance images of 84 patients (84 shoulders) were prospectively analyzed. The biceps-radial magnetic resonance imaging protocol includes sequences acquired in radial planes perpendicular to the long head of the biceps tendon in the shoulder joint. All patients underwent shoulder arthroscopy, and the intraoperative long head of the biceps tendon and pulley lesion findings were compared to the preoperative evaluations. The diagnostic accuracies of the biceps-radial magnetic resonance images and conventional magnetic resonance images were determined. A normal long head of the biceps tendon was observed in 30 (31.6%) patients, partial tears in 43 (52.6%), and complete tears in 11 (15.8%). Normal long head of the biceps tendon stability was present in 54 (61.4%) patients, subluxation in 24 (31.6%), and dislocation in 6 (7.0%). The biceps-radial magnetic resonance (kappa coefficient: 0.94) and conventional magnetic resonance (kappa coefficient: 0.68) images accurately identified long head of the biceps tendon tears. The biceps-radial magnetic resonance images excellently agreed with the arthroscopic findings (kappa coefficient: 0.91), whereas the conventional magnetic resonance images poorly agreed (kappa coefficient: 0.17) regarding long head of the biceps tendon instability. A normal medial wall of the pulley was observed in 26 (31.0%) patients, partial tears in 30 (35.7%), and complete tears in 28 (33.3%). A normal lateral wall of the pulley was observed in 30 (35.7%) patients, partial tears in 21 (25.0%), and complete tears in 33 (39.3%). The biceps-radial magnetic resonance images excellently agreed with the arthroscopic findings (kappa coefficient: 0.89), whereas the conventional magnetic resonance images moderately agreed (kappa coefficient: 0.50) regarding medial pulley lesions. The biceps-radial magnetic resonance images excellently agreed with the arthroscopic findings (kappa coefficient: 0.95), and the conventional magnetic resonance images moderately agreed (kappa coefficient: 0.56) regarding lateral pulley lesions. Biceps-radial magnetic resonance imaging allows for tracking of the long head of the biceps tendon and pulley from the supraglenoid tuberosity to the bicipital groove in the glenohumeral joint and accurate evaluations of long head of the biceps tendon and pulley lesions.

The effect of intravenous tranexamic acid on visual clarity in arthroscopic shoulder surgery compared to epinephrine and a placebo: a double-blinded, randomized controlled trial

The addition of epinephrine in irrigation fluid and the intravenous or local administration of tranexamic acid have independently been reported to decrease bleeding, thereby improving surgeons' visualization during arthroscopic shoulder procedures. No study has compared the effect of intravenous tranexamic acid, epinephrine in the irrigation fluid, or the combination of both tranexamic acid and epinephrine on visual clarity during shoulder arthroscopy with a placebo group. We hypothesized that intravenous tranexamic acid is more effective than epinephrine mixed in the irrigation fluid in improving visualization during shoulder arthroscopy, with no additive effect when both are used. Patients aged ≥18 years undergoing shoulder arthroscopy were randomized into one of 4 study arms: (1) saline irrigation fluid (placebo); (2) epinephrine (0.33 mL of 1:1000 per liter) mixed in irrigation fluid (EPI); (3) 1 g intravenous tranexamic acid (TXA); and (4) epinephrine and tranexamic acid combined (TXA+EPI). Visualization was rated intraoperatively on a scale from 0, indicating poor clarity, to 3, indicating excellent clarity, every 15 minutes and overall. The primary outcome measure was the overall rating of visualization. A stepwise linear regression was performed using visualization as the dependent variable and independent variables including presence or absence of epinephrine and tranexamic acid, surgery duration, complexity, mean arterial pressure, increase in pump pressure, and volume of irrigation fluid. One hundred twenty-eight patients (mean age 56 years) were randomized. Mean visual clarity for the placebo, TXA, EPI, and TXA+EPI groups were 2.0 (±0.6), 2.0 (±0.6), 2.6 (±0.5), and 2.7 (±0.5), respectively (P<.001). The presence or absence of epinephrine was the most significant predictor of visual clarity (P<.001). Tranexamic acid presence or absence had no effect. No adverse events were recorded in any of the groups. Intravenous tranexamic acid is not an effective alternative to epinephrine in irrigation fluid to improve visualization during routine arthroscopic shoulder surgeries, and there is no additive effect when both are used.

Effects of Opioid-Limiting Legislation in the State of Ohio on Opioid Prescriptions After Shoulder Arthroscopy.

Recent studies have shown that legislation regulating opioid prescriptions in the United States has been successful in reducing the morphine milligram equivalent (MME) prescribed after certain orthopaedic procedures. To (1) determine the effect of Ohio's legislation limiting opioid prescriptions after shoulder arthroscopy and (2) identify risk factors associated with prolonged opioid use and increased postoperative opioid dosing. Cohort study; Level of evidence, 3. We reviewed the data of patients who underwent shoulder arthroscopy between January 1, 2016, and March 31, 2020. Patients were classified according to the date of legislation passage (August 31, 2017) as before legislation (PRE) or on/after legislation (POST). Patients were also classified based on the number of opioid prescriptions filled within 30 days of surgery as opioid-tolerant (at least 1 prescription) or opioid-naïve (zero prescriptions). We recorded patient characteristics, medical comorbidities, and surgical details, as well as the number of opioid prescriptions, MME per prescription from 30 days preoperatively to 90 days postoperatively, and the number of gamma-aminobutyric acid (GABA) analogues and benzodiazepine prescriptions from 30 days preoperatively to the date of surgery. Differences between cohorts were compared with the Fisher exact test and Wilcoxon test. A covariate-adjusted regression analysis was used to evaluate risk factors associated with increased postoperative opioid dosing. Overall, 279 patients (n = 97 PRE; n = 182 POST; n = 42 opioid-tolerant; n = 237 opioid-naïve) were included in the final analysis. There was a significant reduction in the cumulative MME prescribed in the immediate (0-7 days) postoperative period (PRE, 450 MME vs POST, 315 MME), the first 30 postoperative days (PRE, 590 MME vs POST, 375 MME), and the first 90 postoperative days (PRE, 600 MME vs POST, 420 MME) (P < .001 for all). The opioid-tolerant cohort had higher MME at every time point in the postoperative period (P < .001). Consumption of preoperative opioid (β = 1682.5; P < .001), benzodiazepine (β = 468.09; P < .001), and GABA analogue (β = 251.37; P = .04) was associated with an increase in the cumulative MME prescribed. Opioid prescription-limiting legislation in Ohio significantly reduced the cumulative MME prescribed in the first 30 days postoperatively for both opioid-naïve and opioid-tolerant patients after shoulder arthroscopy. Consumption of opioids, benzodiazepines, and GABA analogues preoperatively was associated with increased postoperative opioid dosage.

MRI Findings of Periarticular Lesions with Isolated Greater Tubercle Fractures and Dislocation.

To identify MRI findings for injuries to periarticular soft tissue structures that were related to isolated greater tubercle fracture. 16 patients (mean age: 53.8, range 30-71 yrs) were enrolled and diagnosed with isolated greater tubercle (GT) fracture with CT and MRI and underwent shoulder arthroscopy from September 2009 to April 2019. Two musculoskeletal radiologists were blinded to the patient history and arthroscopic surgical findings and reviewed patient's CT and MRI. Fracture displacement, fracture center, and presence of bony Bankart lesion with Hill sachs lesion were checked on shoulder CT. Soft tissue injuries, including rotator cuff injury, deltoid muscle injury, long head of biceps tendon injury, capsular injury, glenoid injury, and injury location of the subscapularis and infraspinatus were checked on shoulder MRI. MRI showed supraspinatus injury (56.3%), subscapularis injury (56.3%), deltoid muscle injury (25%), infraspinatus injury (25%), teres minor muscle injury (37.5%), injury of the long head of the biceps tendon (43.8%), inferior glenohumeral ligament tear (87.5%), superior labral anterior-toposterior lesion (25%), Bankart lesion (18.8%), and Hill-Sachs lesion (6.3%). 88.9% of subscapularis injuries and 75% of infraspinatus injuries showed caudal predominance. All of the patients with infraspinatus injuries showed concomitant teres minor muscle injuries. In order of frequency, the fracture centers were anterior (25%), posterior (31.3%), and all (43.8%). For patients with Bankart and Hill- Sachs lesions, the fracture center included the posterior portion in all cases. MRI and active arthroscopic examinations may be valuable when an isolated GT avulsion fracture is identified on X-ray examination.

Analysis of risk factors for procedure-related hemorrhage in rotator cuff repair surgery under shoulder arthroscopy.

The present study aims to validate the methods of quantifying blood loss in arthroscopic rotator cuff repair and to investigate the correlation between blood loss and joint pain and joint function recovery. A total of 38 patients with unilateral rotator cuff injuries who underwent shoulder arthroscopy were analyzed in this study. Related information, including age, gender, blood pressure, body mass index (BMI), disease entity, comorbidity, joint release, and operating time, were collected into a spreadsheet. Serum hemoglobin and hematocrit (HCT) levels were obtained before the surgery and on the first and third days after the operation. The visual analog scale (VAS) score and the constant-Murley score of the shoulder joint were evaluated 1 year after the operation. Preoperative blood volume (PBV), red blood cell (RBC), hemoglobin (Hb), and HCT levels were significantly higher than those on postoperative day 1 and day 3. The average surgery-related blood loss was calculated to be 435.2 ± 53.6 mL during the surgery and the first postoperative day and 542.5 ± 63.0 mL during the surgery and the first 3 days after the surgery. The VAS score was significantly reduced 1 year after surgery. The multivariate linear regression analysis showed that joint release was a potential risk factor for predicting blood loss 1 or 3 days postoperatively. The actual blood loss from shoulder arthroscopy may be underestimated. The joint release was regarded as the leading risk factor for blood loss.

Mild Biceps Tendonitis May Be Managed Nonoperatively During Shoulder Arthroscopy

The purposes of this study were to determine whether patients with mild biceps tendonitis required revision surgery after the biceps tendon was not surgically treated, while addressing concomitant pathology, and to evaluate whether preoperative groove pain affected patient-reported outcomes. Patients who underwent shoulder arthroscopy between 2015 and 2018 by a single surgeon for rotator cuff pathology, debridement, and distal clavicular excision (DCE), with or without subacromial decompression (SAD), and where the biceps tendon was not surgically addressed were retrospectively identified. Inclusion criteria were mild LS (<50% hyperemic appearing biceps tendon arthroscopically), and a minimum 2-year follow-up. The primary outcome measure was the incidence of revision surgery. Secondary outcomes included American Shoulder and Elbow Surgeons (ASES) score, simple shoulder test (SST), pain level, and satisfaction scores. Two sample t-tests compared postoperative patient-reported outcomes based on the presence or absence of preoperative bicipital groove tenderness. Sixty-four of 69 eligible subjects (93%) were evaluated at a minimum of 2 years postoperatively. One out of 64 subjects underwent revision to perform a biceps tenodesis. Overall, patients had high patient-reported outcome measures (PROMs) postoperatively. Ninety-seven percent of patients reported they would have the surgery again. The presence of preoperative bicipital groove tenderness had no effect on ASES (P= .62), SST (P= .83) scores, and postoperative pain (P= .65). Patients without bicipital groove pain had average respective ASES and SST scores of 93.70 ± 11.84 and 10.66 ± 2.47; those with bicipital groove pain averaged 92.00 ± 15.31 and 10.78 ± 1.87. There was no significant difference in overall satisfaction scores between patients with groove pain (9.42 ± 1.40) and those without (9.46 ± 1.38; P= .92). Patients with mild biceps tendonitis showed favorable outcomes with low revision rates and high patient satisfaction when the biceps tendon was not surgically addressed when the primary shoulder pathology was treated during arthroscopy, independent of preoperative groove pain. Level III, retrospective cohort study.

Preoperative Corticosteroid Injections Within 4 Weeks of Arthroscopic Shoulder Procedures Are Associated With Increased Postoperative Infection Rates

To refine the understanding of the effect of timing of corticosteroid injections (CSIs) and shoulder arthroscopy on postoperative infection. An insurance database was used to determine all patients who underwent shoulder arthroscopy for a 5-year period with an associated preoperative ipsilateral corticosteroid injection. Patients were stratified into cohorts based on timing of preoperative CSI: (1) 0-<2 weeks, (2) 2-<4 weeks, (3) 4-<6 weeks, and (4) 6-<8 weeks. Patients were pooled to include all patients who had a CSI less than 4 weeks and those longer than 4 weeks. A cohort of patients who never had a corticosteroid injection before undergoing arthroscopy were used as a control. All patients had a follow-up of 2 years. Multivariable regression analyses were performed using R Studio with significance defined as P<.05. Multivariate logistic regression showed a greater odds ratio (OR) for postoperative infection in patients who received CSI 0-<2 weeks before shoulder arthroscopy at 90 days (3.10, 95% confidence interval [CI] 1.62-5.57, P<.001), 1 year (2.51, 95% CI 1.46-4.12, P < .001), and 2 years (2.08, 95% CI 1.27-3.28, P= .002) compared with the control group. Patients who received CSI 2-<4 weeks before shoulder arthroscopy had greater OR for infection at 90 days (2.26, 95% CI 1.28-3.83, P= .03), 1 year (1.82, 95% CI 1.13-2,82, P= .01), and 2 years (1.62, 95% CI 1.10-2.47, P=.012). Patients who received CSI after 4 weeks had similar ORs of infection at 90 days (OR 1.15, 95% CI 0.78-1.69, P=.48) 1 year (OR 1.18, 95% CI 0.85-1.63 P= .33), and 2 years (OR 1.09, 95% CI 0.83-1.42, P= .54), compared with the control cohort. The present study shows the postoperative infection risk is greatest when CSIs are given within 2 weeks of shoulder arthroscopy, whereas CSIs given within 2-<4 weeks also portend increased risk, albeit to a lesser degree. The risk of postoperative infection is not significantly increased when CSIs are given more than 1 month before surgery. Level III, retrospective comparative, prognosis study.

Postoperative psychological factors and quality of life but not shoulder brace adherence affect clinical outcomes after arthroscopic rotator cuff repair.

Despite the high prevalence, there is no consensus for postsurgical management after rotator cuff repair. We aimed to assess the impact of psychological well-being on patients who underwent rotator cuff repair. We also investigated correlations and possible predictors between patient demographics and adherence to the use of the shoulder brace and outcomes in terms of shoulder functionality and quality of life. We conducted a retrospective study with prospective data collection enrolling 120 consecutive patients who underwent shoulder arthroscopy for rotator cuff tear repair. Each patient was clinically evaluated after a mean follow-up of 24.2 (±9.8) months using (1)the Disability of the Arm, Shoulder and Hand (DASH) scale, (2) the Hospital Anxiety and Depression Scale (HADS), (3) the Rotator Cuff Quality of Life (RC-QoL), (4) the visual analog scale, and (5) the Medical Adherence Measure. The final sample consisted of 100 patients (45 females, 45%) averaging 60.9 (±8.5) years. The average brace wearing time was 3.4 (±0.6) weeks, with an adherence superior to 80% in 84% of cases, and 96% of patients were living with family members. The mean postoperative DASH scores were 20.1 (±16.7), 23.4 (±25), and 18.9 (±21.5) for the general, work, and sport sections, respectively. The mean Medical Adherence Measure score reached 72.5 (±14.2) points, and the RC-QoL mean score was 30.4% (±20.5). The Hospital Anxiety and Depression Scale-Anxiety and Hospital Anxiety and Depression Scale-Depression scores' continuous mean values were 5.1 (±3.4) and 3.9 (±3.6), respectively. The DASH, Hospital Anxiety and Depression Scale-Anxiety, Hospital Anxiety and Depression Scale-Depression, and RC-QoL scores directly correlated with each other, and all these questionnaires directly correlated with the visual analog scale scores. Moreover, we found a direct correlation (r=0.204, P=.033) between the female sex and adherence to the brace and a direct correlation (r=0.242, P=.015) between adherence to the brace and the number of weeks it was worn according to the medical recommendation. A correlation between lower educational qualifications and poorer outcomes was found. No correlation emerged between adherence to the brace and functional results. According to the regression analysis, diabetes was found to be a predictor of worse postoperative DASH scores (β=0.245, P=0.28). A lower perceived quality of life was associated with worse functional results, anxiety and depression symptoms, and pain after rotator cuff repair surgery. The adherence to the use of the shoulder brace was associated with the female sex and a longer prognosis, but no correlation emerged between adherence to the brace and functional outcomes.

Poster 200: Earlier Evaluation by an Orthopaedic Surgeon Is Associated with Higher Return to Work Among Workers’ Compensation Patients Undergoing Shoulder Arthroscopy

Objectives: Workers’ compensation (WC) patients represent a large expenditure to the health care system and account for a large number of missed work days. Studies have shown that WC patients are less likely to return to work after injury or surgery. The purpose of our study was to determine if there was a higher return to full duty among WC patients who underwent arthroscopic shoulder surgery when they were seen by an orthopaedic surgeon within 100 days of injury. Methods: After obtaining Institutional Review Board approval, a retrospective chart review was conducted of WC patients treated with arthroscopic shoulder surgery by 2 senior authors at a community hospital between 2011 and 2018. WC patients that were treated with arthroscopic shoulder surgery were identified using Current Procedural Terminology (CPT) codes 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, and 29828. Patients were excluded if they were polytrauma patients who had undergone surgical procedures in other locations, patients who had a fracture, and patients being treated with revision shoulder surgery. A total of 59 WC patients were included in the study and were followed up to 2 years post-operatively. WC patients who identified as laborers were divided into 2 groups. The first group was evaluated by an orthopaedic surgeon within 100 days of injury (early orthopaedic evaluation) and the second group was evaluated by an orthopaedic surgeon more than 100 days after injury (late orthopaedic evaluation). The primary outcomes included the length of time from injury to evaluation by an orthopaedic surgeon and from surgery to return to work in some form. Results: Early orthopaedic evaluation was associated with a higher rate of return to full duty (p=0.02). The early orthopaedic evaluation group had a 69% (25 out of 36) return to full duty while the late orthopaedic evaluation group had a return to full duty of 39% (9 out of 23). There was no significant difference in the rate of return to work in some form with the early orthopaedic evaluation group returning at 94% (34 out of 36) and the late orthopaedic evaluation group returning at 83% (19 out of 23). There was a moderate association between time to evaluation by an orthopaedic surgeon following injury and time to return to work in some form (r=.22). There was no significant difference between the groups with respect to the type of laborer (p=.128). Conclusions: WC patients who were evaluated by an orthopaedic surgeon within 100 days of injury had a higher likelihood of return to full duty as well as return to work in some form compared to WC patients who were evaluated by an orthopaedic surgeon more than 100 days after injury. [Table: see text]

Perioperative respiratory and analgesic effects of ultrasound-guided extrafascial versus interfacial interscalene brachial plexus block in patients undergoing shoulder arthroscopy

Perioperative respiratory and analgesic effects of ultrasound-guided extrafascial versus interfacial interscalene brachial plexus block in patients undergoing shoulder arthroscopy

Paper 57: Can 2.0mm Diameter Operative Arthroscopy Predict Appropriate Surgical Management of Intra-Articular Shoulder Pathology More Accurately than MRI? A Prospective, Blinded Clinical Trial

Objectives: The purpose of this study was to compare the intra-articular diagnostic capability of a 2.0mm needle arthroscope to that obtained using MR imaging in patients scheduled to undergo shoulder arthroscopy and determine which was more effective at predicting the appropriate surgical procedure (as defined by CPT code) for patients with glenohumeral pathology. Methods: This study is a prospective, blinded, single-center trial performed with patients who were scheduled to undergo operative arthroscopy for intra-articular shoulder pathology. Thirty consecutive patients were included between May 2020 and July 2020. Each patient underwent an MRI pre- operatively and, on the day of surgery, two recorded diagnostic arthroscopies were performed: the first using a 2.0mm arthroscope, followed by a standard 4.0mm arthroscope. Both videos and MR images were then de-identified and blindly reviewed by two fellowship-trained orthopedic sports surgeons. Analysis included diagnostic agreement of the 2.0mm arthroscope and MRI as compared to the 4.0mm arthroscope which was considered the gold standard. The descriptive quality of the intra-articular pathology as well as the most appropriate treatment recommendation in the form of Current Procedural Terminology (CPT) was compared between the diagnostic modalities. Results: For all intra-articular pathologies except humeral head chondromalacia, the 2.0mm arthroscope had a higher percentage agreement and positive predictive value (PPV) compared to MRI. The 2.0mm arthroscope had a higher sensitivity, specificity, PPV and negative predictive value (NPV) when evaluating the long-head biceps (LHB), superior labrum, infraspinatus, subscapularis and glenoid cartilage. The 2.0mm arthroscope had the highest accuracy when identifying lesions of the LHB (Kappa 0.73) followed by tears of the subscapularis (Kappa 0.65), and articular-sided lesions of the supraspinatus (Kappa 0.62). MRI accuracy was highest when identifying lesions of the LHB (Kappa 0.52), followed by tears of the subscapularis (Kappa 0.31), and articular-sided supraspinatus lesions (Kappa 0.29) but these values were all lower in the MRI group when compared to the 2.0mm arthroscope group. When predicting the appropriate CPT codes for each shoulder, the 2.0mm group had a higher kappa value than the MRI group (kappa 0.87 v 0.56) and a higher agreement percentage (93.1% v 76.7%) (p=0.0003). When considering rotator cuff repair (CPT 29827), the 2.0mm arthroscopy was equally sensitive (93.3 and 93.8) but had a higher PPV as compared to MRI (100 and 83.3). There were no complications related to the use of the 2.0mm arthroscope in this series. Conclusions: 2.0mm arthroscopy is a safe and effective method of diagnosing intra-articular glenohumeral pathology. When diagnosing pathology within the shoulder, the 2.0mm arthroscopy had a higher positive predictive value than MRI when assessing all anatomic pathology except for humeral head chondromalacia. When compared to MRI, the 2.0mm arthroscope was able to more accurately predict which rotator cuff tears would require surgical repair (CPT 29827). When considering all CPT codes for the shoulders in this series, the 2.0mm arthroscope was more accurate at predicting the appropriate surgical procedure (CPT) than the MRI. [Table: see text][Table: see text]

High Rate of Patient Satisfaction with Either Telemedicine or Traditional Office-Based Follow-Up Visit After Arthroscopic Shoulder Surgery.

Background: The purpose of this study was to determine if any differences exist in patient satisfaction with office-based visits versus telemedicine visits following arthroscopic shoulder surgery. Methods: Patients undergoing shoulder arthroscopy were prospectively enrolled for 1 year. Patient demographic and clinical data (including complication events) and second postoperative visit satisfaction data were recorded and analyzed for statistical significance. Results: Ninety-six (n = 96) patients met inclusion criteria. Fifty-four patients (56.3%) participated in a traditional in-person office visit, and 42 participated in a video visit (43.8%). No significant differences were found between office and video appointments in terms of overall care satisfaction (9.46 ± 0.9 vs. 9.55 ± 1.0, p = 0.67). Females were significantly less satisfied with their second postoperative visit compared with males (8.3 ± 2.3 vs. 9.3 ± 1.5, p = 0.035). Significantly more females would also have preferred a traditional in person office visit compared with males (91% vs. 67%, p = 0.009). Video appointment patients spent significantly more time with their surgeon than office visit patients (57.64 mean rank vs. 41.39 mean rank, p = 0.003). Discussion: Video visit patients required significantly less time overall for their visit and spent significantly more time with their surgeon, although did not demonstrate differences in satisfaction.

Does needle penetration of the shoulder joint prior to arthroscopy increase infection risk? The effect of preoperative magnetic resonance arthrogram or corticosteroid injection.

Prior literature has associated preoperative corticosteroid shoulder injection (CSI) with infection following shoulder surgery. A recent study found an equally elevated risk of total knee arthroplasty infection with preoperative injection of either CSI or hyaluronic acid. The implication is that violation of a joint prior to surgery, even in the absence of corticosteroid, may pose an elevated risk of infection following orthopedic surgery. The aim of the present study was to determine whether violation of the shoulder joint for magnetic resonance arthrogram (MRA) poses an elevated risk of infection following shoulder arthroscopy, and to compare this risk to that introduced by preoperative CSI. A national, all-payer database was queried to identify patients undergoing shoulder arthroscopy between January 2015 and October 2020. Patients were stratified into the following groups: (1) no CSI or MRA within 6months of surgery (n=5000), (2) CSI within 2weeks of surgery (n=1055), (3) CSI between 2 and 4weeks prior to surgery (n=2575), (4) MRA within 2weeks of surgery (n=414), and (5) MRA between 2 and 4weeks prior to surgery (n=1138). Postoperative infection (septic shoulder or surgical site infection) was analyzed at 90 days, 1 year, and 2 years, postoperatively. Multivariable logistic regression analysis controlled for differences among groups. MRA within 2weeks prior to shoulder surgery was associated with an increased risk of infection at 1year (odds ratio [OR], 2.17; P=.007), while MRA 2-4weeks preceding surgery was not associated with an increased risk of postoperative infection at any time point. By comparison, CSI within 2weeks prior to surgery was associated with an increased risk of postoperative infection at 90 days (OR, 1.72; P=.022), 1 year (OR, 1.65; P=.005), and 2 years (OR, 1.63; P=.002) following surgery. Similarly, CSI 2-4weeks prior to surgery was associated with an increased risk of postoperative infection at 90 days (OR, 1.83; P<.001), 1 year (OR, 1.62; P<.001), and 2 years (OR, 1.79; P<.001). Preoperative CSI within 4weeks of shoulder arthroscopy elevates the risk of postoperative infection. Needle arthrotomy for shoulder MRA elevates the risk of infection in a more limited fashion. Avoidance of MRA within 2weeks of shoulder arthroscopy may mitigate postoperative infection risk. Additionally, the association between preoperative CSI and postoperative infection may be more attributed to medication profile than to needle arthrotomy.

Total intravenous anesthesia compared to traditional general anesthesia in shoulder arthroscopy with interscalene block in the beach chair position

Shoulder arthroscopy is commonly performed in the beach chair position, which has been linked to cerebral oxygen desaturation. Previous studies comparing general anesthesia (GA) to total intravenous anesthesia (TIVA) using propofol indicate that TIVA can preserve cerebral perfusion and autoregulation, as well as shorten recovery time and reduce the incidence of postoperative nausea and vomiting. However, few studies have evaluated the use of TIVA in shoulder arthroscopy. Thus, this study seeks to determine if TIVA is superior to traditional GA methods in terms of improving operating room efficiency, shortening recovery time, and reducing adverse events while theoretically preserving cerebral autoregulation in patients undergoing shoulder arthroscopy in the beach chair position. This is a retrospective study of patients undergoing shoulder arthroscopy in the beach chair position, comparing 2 anesthetic techniques. One hundred fifty patients were included (75 TIVA and 75 GA). Unpaired t-tests were used to determine statistical significance. Outcome measures included operating room times, recovery times, and adverse events. Compared to GA, TIVA significantly improved phase 1 recovery time (53.2±32.9 min compared to 65.8±41.3 min; P=.037) and total recovery time (120.3±31.0 min compared to 131.5±36.8 min; P=.048). TIVA also decreased time from case finish to out-of-room (6.5±3.5 min compared to 8.4±6.3 min; P=.021). However, the in-room to case start time was slightly longer for the TIVA group (31.8±7.22 min compared to 29.2±4.92 min; P=.012). Although not statistically significant, there were fewer readmissions in the TIVA group compared to the GA group (P=.08), and TIVA had lower rates of postoperative nausea and vomiting (P=.22) and higher intraoperative mean arterial pressures (87.1±11.4 mmHg in the TIVA group compared to 85.0±9.3 mmHg in the GA group; P=.22). TIVA may be a safe and efficient alternative to GA in shoulder arthroscopy in the beach chair position. Larger scale studies are needed to evaluate the risk of adverse events related to impaired cerebral autoregulation in the beach chair position.